Diagnostic accuracy of MRI contrast enhanced FLAIR and T1-weighted images in diagnosis of infectious meningitis taking CSF analysis as reference standard
DOI:
https://doi.org/10.61529/idjp.v35i2.535Abstract
Background: Early diagnosis of infectious meningitis is critical to reduce morbidity and mortality, particularly in paediatric patients where delayed diagnosis may lead to severe neurological complications.
Material and Methods: This Cross-sectional study was conducted at Department of Diagnostic Radiology, Sir Ganga Ram Hospital, Lahore, from 3rd January 2026 to 10th April 2026. A total of 154 children aged ≤15 years with clinical suspicion of infectious meningitis were enrolled through non-probability consecutive sampling. All participants underwent contrast-enhanced FLAIR and post-contrast T1-weighted brain MRI. CSF analysis, including cytological, biochemical, and microbiological assessment, was used as the reference standard as CSF findings consistent or not consistent with infectious meningitis.
Results: The mean age was 8.17 ± 4.4 years, and 90 (58.4%) participants were male. CSF findings were consistent with infectious meningitis in 104 (67.5%) cases. Contrast-enhanced FLAIR MRI showed leptomeningeal enhancement suggestive of infectious meningitis in 100 (64.9%) patients, whereas post-contrast T1-weighted MRI was positive in 93 (60.4%) patients. CE-FLAIR showed a sensitivity, specificity, PPV, NPV, and overall accuracy of 92.3%, 92.0%, 96.0%, 85.2%, and 92.2%, respectively. Corresponding values for post-contrast T1-weighted MRI were 81.7%, 84.0%, 91.4%, 68.9%, and 82.5%, respectively.
Conclusion: Contrast-enhanced FLAIR MRI showed higher sensitivity, specificity, predictive values, and overall diagnostic accuracy than post-contrast T1-weighted MRI for detecting infectious meningitis.
Keywords: Cerebrospinal fluid, Child, Magnetic resonance imaging, Meningitis, Sensitivity and specificity
References
Kohil A, Jemmieh S, Smatti MK, Yassine HM. Viral meningitis: An overview. Arch Virol. 2021; 166(2): 335-45. DOI: https://doi.org/10.1007/s00705-020-04891-1
Wabasa NA, Maria DE, Naseem KA, Mujahid NA, Faheem AR, Aslam SU. Positive predictive value of contrast-enhanced fluid-attenuated inversion recovery (CE-FLAIR) MRI in diagnosing meningitis. Pak J Med Health Sci. 2022; 16(1): 199-200. DOI: https://doi.org/10.53350/pjmhs2216199
Zainel A, Mitchell H, Sadarangani M. Bacterial meningitis in children: Neurological complications, associated risk factors, and prevention. Microorganisms. 2021; 9(3): 535. DOI: https://doi.org/10.3390/microorganisms9030535
Bhagawati A, Dhanowar LN, Dhanowar RK, Choudhury G, Borah P, Dharavath V. Diagnostic accuracy of contrast-enhanced FLAIR magnetic resonance imaging in detecting meningeal abnormalities in suspected cases of infectious meningitis. Int J Sci Res Dent Med Sci. 2024; 6(4): 157-62. DOI: https://doi.org/10.30485/IJSRDMS.2025.493 096.1625
Khalid MS, Arooj S, Asghar A, Mansoor A, Masood M, Afzal F. Diagnostic accuracy of contrast-enhanced T2 FLAIR in diagnosing infective meningitis considering CSF analysis as the gold standard. Pak Postgrad Med J. 2023; 34(3): 125-30. DOI: https://doi.org/10.51642/ppmj.v34i03.606
Roozpeykar S, Azizian M, Zamani Z, Farzan MR, Veshnavei HA, Tavoosi N, et al. Contrast-enhanced T1-weighted and FLAIR sequences in MRI of meningeal lesions. Am J Nucl Med Mol Imaging. 2022; 12(2): 63-70. Available from: https://pmc.ncbi.nlm.nih.gov/articles/ PMC9077169/pdf/ajnmmi0012-0063.pdf
Mehmood S, Khan MI. Diagnostic Accuracy of Post Contrast Magnetic Resonance Imaging for Meningitis Taking Lumbar Puncture as Gold Standard. Indus J Bioscience Res. 2025; 3(5): 426-9. Available from: https://ijbr.com.pk/IJBR/article/view/1344
Jawwad S, Gul N, Mehmood K, Iqbal B, Afzal K. Diagnostic accuracy of contrast-enhanced FLAIR magnetic resonance imaging in the diagnosis of meningitis using lumbar puncture as the gold standard. Life Sci. 2022; 3(3): 120-6. doi: http://doi.org/10.37185/LnS.1.1.259
Vaswani AK, Nizamani WM, Ali M, Aneel G, Shahani BK, Hussain S. Diagnostic accuracy of contrast-enhanced FLAIR magnetic resonance imaging in diagnosis of meningitis correlated with CSF analysis. ISRN Radiol. 2014; 2014: 578986. DOI: https://doi.org/10.1155/2014/578986
Shabbir S, Sheikh M. Positive predictive value of contrast-enhanced fluid-attenuated inversion recovery magnetic resonance imaging in diagnosis of meningitis among paediatrics using cerebrospinal fluid analysis as gold standard. Cureus. 2024; 16(11): e73356. DOI: https://doi.org/10.7759/cureus.73356 .
La Russa R, Maiese A, Di Fazio N, Morano A, Di Bonaventura C, De Matteis A, et al. Post-traumatic meningitis is a diagnostic challenge: A systematic review focusing on clinical and pathological features. Int J Mol Sci. 2020; 21: 4148.
DOI: https://doi.org/10.3390/ijms21114148
Hazarika RD. Invasive meningococcal disease: A review. Pediatr Infect Dis. 2019; 3: 95-107.
DOI: https://doi.org/10.5005/jp-journals-10081-1215
Hasbun R. Progress and challenges in bacterial meningitis: A review. JAMA. 2022; 328: 2147-54. DOI: https://doi.org/10.1001/jama.2022.20521
Li S, Nguyen IP, Urbanczyk K. Common infectious diseases of the central nervous system: Clinical features and imaging characteristics. Quant Imaging Med Surg. 2020; 10: 2227-59. DOI: https://doi.org/10.1001/jama.2022.20521
Roozpeykar S, Azizian M, Zamani Z, Farzan MR, Veshnavei HA, Tavoosi N, et al. Contrast-enhanced weighted-T1 and FLAIR sequences in MRI of meningeal lesions. Am J Nucl Med Mol Imaging. 2022; 12(2): 63-70.
Jia, Tabassum S, Haider S, Haania. Diagnostic accuracy of diffusion weighted MRI in differentiating malignant from benign liver lesions taking histopathology as gold standard. Pak J Med Sci. 2024; 40(4): 669-73.
DOI: https://doi.org/ 10.12669/pjms.40.4.7738
Shakoor S, Fatima T, Mir F, Shahid A, Shaheen N, Khan E, et al. Etiology of acute infectious meningitis and meningoencephalitis in Karachi, Pakistan: A retrospective observational study. Am J Trop Med Hyg. 2023; 109: 450-9. DOI: https://doi.org/10.4269/ajtmh.23-0182
Seid G, Alemu A, Dagne B, Gamtesa DF. Microbiological diagnosis and mortality of tuberculosis meningitis: A systematic review and meta-analysis. PLoS One. 2023; 18. DOI: https://doi.org/10.1371/journal.pone.0279203 .
Gad M, Elsorogy LG, Moustafa SAF. Diagnostic utility of contrast-enhanced FLAIR MRI in imaging of demyelinating and infectious brain lesions. Egypt J Radiol Nucl Med. 2023; 54: 104. DOI: https://doi.org/10.1186/s43055-023-01049-2
Gundamraj V, Hasbun R. Viral meningitis and encephalitis: An update. Curr Opin Infect Dis. 2023; 36: 177-85.
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